Wednesday, March 24, 2010

The Unfinished Business of Healthcare Reform

It seems to me that Monday's celebrations over the passage of the healthcare reform act were a bit premature. As one of the 50 million uninsured, I couldn't help but notice a couple of things. Sure, I'll have to wait 4 years to get my coverage. The patients' exchanges have to be set up first.

But what if I'm in the group of 18 million uninsured whom Sunday's bill does nothing for? And what if I want an abortion? (Just kidding!)

Since when does taking care of 60% of a problem mean solving the whole problem? I'm sure President Obama didn't get into Columbia College and Harvard Law School getting 60's on his tests.

Here's the second thing that Sunday's bill didn't do: it did absolutely nothing to lower healthcare costs in the long run. Quite the opposite. It just committed the government to giving one or two trillion dollars to private health insurance companies with no guarantee whatsoever that the companies won't raise their premiums. Sunday's bill gave private insurance the same blank check that the government has already given Wall Street.

What's done is done, I suppose. As long as China keeps loaning us the money, I guess it doesn't matter which tiny group of rich people we make fabulously richer with taxpayers' money.

But how about a cost-neutral plan to take care of the forgotten eighteen million, a plan that would show the rest of the healthcare goniffs how to improve outcomes while lowering costs?

I'm talking, of course, about using the PHS. The PHS would be our public option, reconsitituted with the return of the VA's infrastructure and its $50 billion a year budget. It would continue to care for its current 3 million veterans, although this number drops by 1,000 every week with the death of WWII and Korean War veterans. But the new PHS would pick up the care of the abandoned 18 million uninsured, all for a cost of $50 billion a year.

If Medicare and the NIH (specifically, the NIDDK) bothered to do their jobs and eradicate 90% of kidney failure, now that it's been possible since 2002, there'd be an additional $50 billion a year available (see

The VA/reconstituted PHS could take care of 21 million without hiring a single extra staff member. Just get the current VA physicians, who see patients one half-day a week, to hold clinics four full days a week.

Then use the PHS to lead the way in lowering cost. Have the PHS report the outcome of each and every patient, each and every year. While Medicare is experimenting tentatively with clinical effectiveness research (CER), let the PHS take the problem seriously, using every one of its 21 million patients as a guide to what works and what doesn't, and how to do things more cheaply.

Then post the PHS's outcomes on the Internet for all to see. Patients in private health plans and Medicaid and Medicare, if they have any interest, can start asking their doctors why their toes are still being amputated, but diabetic patients in the PHS haven't had any amputations for the past 15 years. Patients with a bit more initiative might just drop their coverage, and let the PHS take care of them for free.

Of course, a free PHS that anybody could use would throw a monkey-wrench into the mandated health insurance system that just passed Sunday night. It would provide a free "out" to any American who didn't feel like paying thousands of dollars to a private insurer to get second rate care. It might even kill the exchanges, which I don't think would be such a bad thing, because the PHS is a much cheaper and more controllable alternative.

A robust and free PHS would certainly give all Americans more choice. It would ensure greater competition. It wouldn't cost an extra cent. It would provide an escape valve for any system that continued to price itself out of the reach of ordinary Americans, or went bankrupt, as the Massachusetts experiment is heading towards.

And, perhaps most importantly, a reconstituted PHS would save the VA's infrastructure from destruction, something nobody at the VA or the government is even talking about right now. For the first time in a long time, government would have demonstrated that it could grow taxpayers' investment over 80 years and return it to the taxpayers for their own use even better than before. For the first time in many years, the government would not have just flushed taxpayers' money down the drain.

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